In light of the rapid spread of coronavirus disease 2019 (COVID-19) across the United States, the Centers for Disease Control and Prevention (CDC) and hospitals nationwide have developed new protocols to address infection control as well as the care of critical patients. Airway management has been particularly difficult; the challenge of quickly establishing an airway in patients must be balanced by the risk of aerosolizing respiratory secretions and putting the provider at risk of infection. Significant attention has been given to developing protocols for the emergency department and critical care units, but little guidance regarding establishing airway and respiratory support for patients in the prehospital setting has been made available. While some of the recommendations can be extrapolated from hospital guidelines, other factors such as environment and available resources make these protocols unfeasible. Through review of current literature the authors established recommendations regarding airway management and the provision of respiratory support to patients developing respiratory failure related to COVID-19.
We are facing a global coronavirus disease 2019 (COVID-19) pandemic since the virus emerged in Wuhan, China. Although this virus does not discriminate on the basis of race, ethnicity, gender, or socioeconomic status, it has the highest mortality rate in older adults. Mentation is an important part of the geriatric evaluation, as it is listed as part of the age-friendly healthcare framework that incorporates four key interventions – what matters; medication; mentation; and mobility (4Ms). Geriatric conditions such as delirium, dementia, and depression will confound an emergent evaluation because of an atypical manifestation of COVID-19 and non-COVID-19 related illness. Furthermore, these conditions are exacerbated by the effects of either social distancing or the financial crisis on vulnerable members of society.1 There is a particular concern that delirium will increase amid the COVID-19 pandemic due to the use of infectious disease isolation, and also pose a unique challenge to the evaluation of mentation in older adults, due to both COVID-19 and the common central nervous system (CNS) pathology not related to the COVID-19 such as cerebrovascular accident (CVA).
The coronavirus disease 2019 (COVID-19) pandemic is a public health crisis that has quickly overwhelmed our healthcare system. It has led to significant shortages in personal protective equipment (PPE), ventilators, and intensive care unit beds across the nation. As the initial entry point for patients with suspected COVID illness, emergency departments (ED) have had to adapt quickly to prioritize the safety of patients and providers while still delivering optimal, timely patient care. COVID-19 has presented many challenges for the ED that also extend to all inpatient services. Some of these key challenges are the fundamental tasks of communicating with patients in respiratory isolation while minimizing PPE usage and enabling all patients who have been affected by hospitals’ visitor restrictions to connect with their families. We discuss the design principles behind implementing a robust in-hospital telehealth system for patient-provider and patient-family communication, provide a review of the strengths and weaknesses of potential videoconferencing options, and deliver concise, step-by-step guides for setting up a secure, low-cost, user-friendly solution that can be rapidly deployed.
The coronavirus disease 2019 (COVID-19) pandemic caused by the coronavirus SARS-CoV-2 has radically altered delivery of care in emergency settings. Unprecedented hardship due to ongoing fears of exposure and threats to personal safety, along with societal measures enacted to curb disease transmission, have had broad psychosocial impact on patients and healthcare workers alike. These changes can significantly affect diagnosing and managing behavioral emergencies such as agitation in the emergency department. On behalf of the American Association for Emergency Psychiatry, we highlight unique considerations for patients with severe behavioral symptoms and staff members managing symptoms of agitation during COVID-19. Early detection and treatment of agitation, precautions to minimize staff hazards, coordination with security personnel and psychiatric services, and avoidance of coercive strategies that cause respiratory depression will help mitigate heightened risks to safety caused by this outbreak.
The COVID-19 pandemic will, slowly, and with some hiccups and many tragedies, pass into memory. This coronavirus may disappear and later recur, continue endemically under vaccine control, or simply attenuate and vanish.1 The economy and healthcare systems will return to a new normal, some parts more quickly than others. Like the multiple plagues humanity has endured since our ancestors gathered into cities, it will generate recriminations for slow and misguided responses, profiteering, and overor underreacting to economic, social, and healthcare events that will, retrospectively, be obvious.2 The individuals and organizations most culpable for exacerbating the disaster (e.g., many national and some state political leaders) will escape responsibility while they scapegoat others and try to re-write history. Heroes, whether individuals who helped provide clear risk communication and leadership (e.g., Anthony Fauci, MD, of the National Institutes of Health; Sanjay Gupta, MD, of CNN; and Li Wenliang, MD, who died while trying to notify the world about the pandemic) or groups that persevered in the face of fear and life-threatening danger (e.g., emergency department, intensive care unit, emergency medical services, and other critical healthcare staff and first responders) will emerge. Without fanfare, most will return to their normal jobs, scarred but proud of their efforts. As they have before, pundits and scholars will write endlessly about the pandemic’s cause, effects, and ways to ameliorate the next pandemic’s brutal destruction of lives and ways of life. The problem is, we have done all this before and seem not to have learned the lessons our predecessors taught.
Boarding, the practice of holding patients in emergency departments (ED) after a decision has been made to admit them to the hospital,1 is well known to adversely affect patient care. Multiple investigations have shown that boarding negatively impacts quality and patient safety outcomes including mortality,2-7 readmission rate,8 hospital length of stay,2,5,8,9 and patient satisfaction.10-12 In addition, boarding is known to be a major contributor to overall ED crowding,13 which also has been demonstrated to have significant negative impact on quality and safety.13,14 Multiple operational tactics are known to reduce boarding but, concerningly, adoption of them has been inconsistent.13,15 Also concerning, ED boarding appears to be worsening over time, based upon our unpublished year-over-year review of two large national ED operations benchmarking databases, the Emergency Department Benchmarking Alliance and the Academy of Administrators in Academic Emergency Medicine/Association of Academic Chairs of Emergency Medicine.16,17
In a 2014 editorial, Shy pointed out a statistical error in ECASS III.3 The trial’s reported adjusted primary analysis did not account for the baseline imbalance in prior stroke status. The ECASS III authors have not addressed this statistical error in the literature. In a recent publication, Alper et al used the raw data to reanalyze the ECASS III data with appropriate adjustments. In a multivariate model adjusted for both baseline National Institutes of Health Stroke Scale (NIHSS) scores (P = .03 between groups) and prior stroke status (P = .003 between groups) there was a non-significant difference between alteplase and placebo for all efficacy outcomes.4
Some experts have promoted the use of rapid testing for COVID-19. However, with the current technologies available, continuing to replace laboratory-based, real-time reverse transcription polymerase chain reaction tests with rapid (point-of-care) tests may lead to an increased number of false negative tests. Moreover, the more rapid dissemination of false negative results that can occur with the use of rapid tests for COVID-19 may lead to increased spread of the novel coronavirus if patients do not understand the concept of false negative tests. One means of combatting this would be to tell patients who have a “negative” rapid COVID-19 test that their test result was “indeterminate.”
Reducing cost without sacrificing quality of patient care is an important yet challenging goal for healthcare professionals and policymakers alike. This challenge is at the forefront in the United States, where per capita healthcare costs are much higher than in similar countries around the world. The state of Maryland is unique in the hospital financing landscape due to its “capitation” payment system (also known as “global budget”), in which revenue for hospital-based services is set at the beginning of the year. Although Maryland’s system has yielded many benefits, including reduced Medicare spending, it also has had unintentional adverse consequences. These consequences, such as increased emergency department boarding and ambulance diversion, constrain Maryland hospitals’ ability to fulfill their role as emergency care providers and act as a safety net for vulnerable patient populations. In this article, we suggest policy remedies to mitigate the unintended consequences of Maryland’s model that should also prove instructive for a variety of emerging alternative payment mechanisms.
Many public officials are calling for increased testing for the 2019 novel coronavirus disease (COVID-19), and some governments have taken extraordinary measures to increase the availability of testing. However, little has been published about the sensitivity and specificity of the reverse transcriptase-polymerase chain reaction (RT-PCR) nasopharyngeal swabs that are commonly used for testing.
As an emergency and wellness physician, scientist, father, and 55-year-old man, I have a keen interest in the coronavirus and the resulting COVID-19/severe acute respiratory syndrome (SARS) CoV2 illness. Based on all I have heard from the scientific community, a review of the literature, and a review of historical facts related to other epidemics, I believe we are missing some key points, particularly with regard to how we are approaching prevention of morbidity and mortality.
As clinicians and support personnel struggle with their responsibilities to treat during the current COVID-19 pandemic, several ethical issues have emerged.
During the current COVID-19 pandemic, the limited surge capacity of the healthcare system is being quickly overwhelmed. Similar scenarios play out when an institution’s systems fail, or when local or regional disasters occur. In these situations, it becomes necessary to use one or more alternative care sites (ACS).
In disasters such as the COVID-19 pandemic, we need to use all available resources to bolster our healthcare workforce. Many factors go into this process, including selecting the groups of professionals we will need, streamlining their licensing and credentialing processes, identifying appropriate roles for them, and supporting their health and well-being.
The ongoing spread of COVID-19, also known as the novel coronavirus, has created significant concerns often leading to panic throughout the world as to its virulence and lethality. Regularly published media track newly infected patient rates and deaths further driving public panic, which invariably leads to people seeking information.
The global novel coronavirus (COVID-19) pandemic continues to worsen and has become one of the largest clinical and operational challenges faced by emergency medicine since its inception as a specialty. As the virus spreads across the United States, our emergency departments (ED) continue to see increased volumes of infected patients, many of whom are not only critically ill, but acutely aware and fearful of their circumstances and potential mortality.
Across the world, efforts are underway to contain the spread and mitigate the impact of COVID-19. These include social distancing efforts such as working from home and meeting via teleconferences.8 The nature of public safety both necessitates that first-responder personnel be present at the station and requires vigilance to keep them healthy to provide essential services to the community. As a result, the fire station represents a front line in the COVID-19 mitigation efforts.
